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Telemedicine
' Telemedicine' is the use of communication technologies to deliver health care services over a distance. Telemedicine can be used to provide services at remote or hostile locations. Telemedicine, telehealth and eHealth are sometimes used interchangeably. In general, however, telemedicine tends to be associated with direct patient clinical services. American Telemedicine Association. Telemedicine/Telehealth Terminology, American Telemedicine Association website, Washington, D.C. Retrieved April 24, 2012. Perhaps the most important feature of telemedicine is its ability to bridge distance gaps. In poor and rural areas, this increases the availability of specialists which are often in demand. In some cases, telemedicine may provide access to doctors in extremely isolated areas such as for climbers of mount Everest EverestNews.com. Everest 2010: Extreme Telemedicine , Retrieved May 20, 2012. or researchers in Antarctica Australian Antarctic Division. Medical Facilities on Station Australian Government Website, Kingston Tasmania, Australia. Retrieved May 20, 2012. . Telemedicine allows for provider shortages to be dealt with in everything from normal day to day operations to disaster situations. Examples of such coverage include running radiology services 24/7 by utilizing physicians in other parts of the world MSNBC.com. Some U.S. hospitals outsourcing work Retrieved May 20, 2012., and furnishing disaster aid following the 1985 earthquake in Mexico City Garshnek, V.,& Burkle, F. M., Jr. (1999) Applications of telemedicine and telecommunications to disaster medicine: historical and future perspectives. J Am Med Inform Assoc, 6(1), 26-37. Disambiguation Because telemedicine is an adopted name, and perhaps not as socially relevant of a term today with the word "telephone" no longer able to describe all the voice chatting technology that exists today, other terms such as "telehealth" and "eHealth" have been used to describe the same set of technologies. As the American Telemedicine Association points out American Telemedicine Association. Telemedicine/Telehealth Terminology, American Telemedicine Association website, Washington, D.C. Retrieved April 24, 2012., telemedicine specifically refers to the application of patient health care, whereas telehealth or eHealth can refer to non-clinical provisions such as student, doctor or patient education. The prevalence of which term is used to describe health care at a distance using telecommunication technologies appears to vary from country to country and between social and economic groups. One who works as a telemedicine specialist, for example, would be more likely to use the term telemedicine, than a website programmer who may be more used to terms with an e in front of the term to denote its online presence. In his introduction to telemedicine book, Wootton differentiates between additional types of care with more telewords. He views telecare as "the provision, at a distance, of nursing and community support." Telehealth, he states, refers to "public health services delivered at a distance, to people who are not necessarily unwell, but who wish to remain well and independent." Wootton uses the term health telemetrics''as his umbrella term for all health-related activities carried out over a distance. Finally, his definition of telemedicine is as follows: "rapid access to shared and remote medical expertise by means of telecommunications and information technologies, no matter where the patient or the relevant information is located." Wootton, R., Craig, J., & Patterson, V. (2006). Introduction to telemedicine (2nd ed.). London Ashland, Ohio: Royal Society of Medicine Press History While many do not think of the start of telemedicine until the advent of video conferencing, or perhaps the advent of the telephone, technically the origins of telemedicine are much earlier. While it is hard to pinpoint an exact moment in time the first examples of telemedicine start, there are many early history examples of telemedicine. One such example is the transportation of information about the bubonic plague in the middle ages. Bonfires would signal where the plague had claimed a significant number of livesCash, Carolyn M. The Great Plague of London. Retrieved July 5th, 2012.. Postal services were the next big development in telemedicine. Personal health care was able to be delivered at a distance through a reliable and complex means (can only transmit so much information through simpler means, such as the bonfire example) and the practice of diagnosis and prescription was established . The next major development came with the advent of the telegraph. The telegraph was used in the civil war to transmit casualty lists and to order medical supplies . Advancements in telegraph technology allows for the transmission of x-ray images Chen, Yung-fu. Chapter 19 Telehealth and Communication. Retrieved June 22nd, 2012.. By the early 1900s, the telephone lines had been developed enough to transmit ECG and EEG signals . By 1910, amplification of stethoscope sounds could be transmitted via telephone - a technology that is still in use today . According to Richard Kimball, CEO of health tech startup company HEXL, telemedicine began in the mid-90s. In addition, in the early 1900s, radio technology was coming about. Quite quickly there was an adoption for medical advice to be given over radio (especially for seafarers who often need medical advice but are not near any doctors). In 1920, the Seaman's Church Institute of New York became one of the first organizations to provide medical care using the radio. In 1935 the CIRM (international radio medical centre) in Rome was established. It is currently the largest organization in the world providing health care to seafarers. Radio medical device for air journeys also saw adoption quite early in the advent of air travel. Video telemedicine started around 1960s. The first major CCTV set-up was established in 1964 between the Nebraska Psychiatric Institute in Omaha and the state mental hospital in Norfolk, 112 miles away Benschoter RA, Wittson CL, Ingham CG. Teaching and consultation by television: 1. Closed-circuit collaboration. J Hosp Commun Psychiatry 1965; 16:99-100.. Perhaps the first application of telemedicine to increase access to care for a remote area was the establishment of a television linking doctors and patients of the Massachusetts General Hospital to the Logan International Airport (LIA) Medical Station in 1967. Nurses at the LIA medical station provided care, assisted by physician expertise Murphy RLH, Bird KT. Telediagnosis: a new community health resource. Obersvations on the feasibility of telediagnosis based on 1000 patient transactions. Am J Public Health 1975;64:113-19.. The next major development in providing care to rural and extreme environments came with the Alaska AS-6 Satellite Biomedical Demonstration of 1971-1975, which assessed the viability of improving village health care in Alaska through the use of satellite mediated video consultation Foote DR. Satellite communication for rural health care in Alaska. J Commun 1977;27:173-82.. With the proliferation of internet technology and the ever increasing use of video conferencing technology through applications such as skype and facetime, perhaps the next major leap in doctor-patient interactions will come through a project promoting the mass adoption of smartphone/webcam technologies to contact doctors or trained professionals for one's health needs. Technologies Employed By and large telemedicine can be categorized by the time-frame in which the consultations occur. Common telemedicine methods include but are not limited to: store-and-forward, remote monitoring, and videotelephony or interactive telemedicine. Store-and-Forward '''Store-and-forward' is the type of telemedicine with the most time delay. It works precisely how it sounds - a consultation or evaluation is video recorded and stored. At some future point in time, this video is then forwarded to a specialist or another doctor. Because the file is not streaming, technological issues that might effect the quality such as internet bandwidth do not come into play. Video compression can be used to decrease the file size if desired. Store-and-forward may be necessary in areas where networks are not dedicated or are intermittent in connectivity (such as mobile and/or extremely rural areas). Remote Monitoring Remote monitoring is the monitoring of a patient remotely. Many technology fall within this category. Baby monitors, for example, are a fairly low tech form of remote monitoring. Internet activated electrocardiograms (ECGs) Wireless Cardio Monitoring System, 24eight.com. Retrieved May 18th, 2012., embedded homecare monitoring systems Dobrescu, R. Embedded Wireless Homecare Monitoring System, eHealth, Telemedicine, and Social Medicine, 2009. eTELEMED '09. International Conference on, Politeh., Univ. of Bucharest, Bucharest. 1-7 Feb. 2009., and other sophisticated remote monitoring systems exist and are in use in hospitals and other specialized care facilities around the world. Sophisticated remote monitoring systems may incorporate subjective questioning on the patients health and with assistance from computer programs automatically flag the doctor when things are going awry. These systems need not only exist in a hospital, in fact, such systems have been developed for the remote monitoring of elderly patients utilizing wireless sensors and smart phone technology in order to allow the elderly to stay at home (as opposed to assisted living) for longer periods of time Ziyu Lv, Feng Xia, Guowei Wu, Lin Yao, Zhikui Chen, iCare: A Mobile Health Monitoring System for the Elderly Arxiv.org, Dalian 116620, China. Retrieved June 1st, 2012. Telemonitoring also exists outside the clinical realm with websites that allow tracking of weight, food intake, exercise, etc Fitday.com. Retrieved June 1st, 2012. WebMD Food and Fitness Planner. Retrieved June 1st, 2012. Livestrong.com MyPlate. Retrieved June 1st, 2012.. Additional services such as health vault by Microsoft Microsoft HealthVault. Retrieved 1st June, 2012., and the now extinct Google Health Google Health. Retrieved 1st June, 2012. allow for upload/report of data from devices that measure blood pressure, weight, glucose levels, hemoglobin levels, etc Microsoft HealthVaultManaging a chronic condition. Retrieved 1st June, 2012.. In addition, they may allow linking to your personal health record (if available electronically from your provider) Microsoft HealthVault Organizing your medical records. Retrieved 1st June, 2012. . Interactive Telemedicine Interactive telemedicine is perhaps the best known telemedicine because it is the style of telemedicine closest to an in-person consultation. While it is contemporarily thought of as real time video chatting, technically any real-time interaction would fall under this category Sachpazidis, Ilias Image and Medical Data Communication Protocols for Telemedicine and Teleradiology(dissertation), Department of Computer Science, Technical University of Darmstadt, Germany, 10 July 2008.. Nearly any sort of consultation can be conducted in this manner, however, in some circumstances this may require specialized equipment such as electronic stethoscopes Electronic Stethoscope WhitePaper, Telehealth Technology Assessment Center, telehealthtac.org. Retrieved 28th May 2012. or other various paraphernalia. In some cases, hospitals have even began to include remote robotic systems Advanced ICU. Icumedicine.com. Retrieved May 22nd, 2012, to assist doctors and nurses in evaluating patients. Other benefits of interactive telemedicine include the possibility for cheaper operating costs Gary C. Doolittle, M.D., Ashely O'Neal Spaulding, M.A., and Arthur R. Williams, Ph.D. The Decreasing Cost of Telemedicine and Telehealth. Telemedicine and e-Health 17(9). November 2011:671-675. , the reduction of travel time and costs, and increased specialist availability in remote and rural areas. Collaboration While collaboration is not its own category it is important to mention that collaboration is possible using any of archetypes of technology. Combining the telemedicine information from the patient through store-and-forward, remote monitoring or interactive telemedicine, multiple doctors can collaborate on particularly challenging or unique cases. For many electronic health records (and add-on technology for major EHRs), collaboration technologies are already build into the system, allowing for multiple doctors to view the same patient and patient information OnBase software solutions, Top hospital realizes local and global interoperability with ECM-EMR integration, Hyland.com. Retrieved June 1st, 2012.. Even in the case of EMRs without collaboration integrated, the usual voice, video, or internet conferencing can be used to share information and collaborate. In addition, similar technologies may be employed to teach students via a live feed to a patient or patients. One should always be careful, however, of ensuring adequate security to ensure HIPAA compliance. State laws may add additional HIPAA rules and should be taken into consideration as well. Licensing and Regulatory Issues It is generally viewed as the physician being transported to the patient, not visa versa. This requires the physician to be licensed in the location that the patient is. This brings up some obvious issues for rural areas and areas of extreme isolation, limiting the use of some rare specialists. Because of the requirement to be licensed in the state or country in which you are practicing telemedicine, adoption has been slow. Licensing may take a significant amount of time and money, and often has fees, may require oral and/or written examinations, and traveling for interviews. In general, it is a good idea to consult Medical Board Regulations of the state or country which you intend to practice before attempting to set up a telemedicine program in that area MedLicense.com - Practical Advise for Physicians who are Involved in Telemedicine. Retrieved July 1st, 2012.. One way to get around licensing issues is to provide 'advice' to your client (a physician or nurse on the other side). Doctors often consult with each other and specialists on particularly difficult cases. Depending on the state or country the local physician is located (not to mention how good their malpractice insurance is) this may or may not be feasible. This avoids the issue of licensing because the consultant (telemedicine provider) is not diagnosing anything. Cost of Implementation and Return on Investments Unfortunately, there are not too many reports available that provide a cost/benefits analysis of telemedicine. Telemedicine is still fairly new and is primarily being adopted at locations where being at the forefront of technology is more important than conserving costs or maximizing profit. In 2011 a study was published which has intricately tracked the costs of a telemedicine program established at the University of Kansas Medical Center in Kansas City. U of K has been running a telemedicine program since 1992 and has been meticulously watching the cost of the program. The average cost per patient has dramatically decreased since establishing the program. For example, the average cost of Teleoncology has dropped from $812 per visit in the fiscal year of 1995 to $251 per visit in the fiscal year of 2005 Doolittle, Gary C., Spaulding, Ashley O., and Williams, Arthur R. (2011). The Decreasing Cost of Telemedicine and Telehealth. Telemedicine and e-Health. 17(9): 671-675.. The costs calculated in this study included the following: * room rent (compared to average rental figure for commercial office space of same sq. footage) * equipment costs * telecommunication line charges * salaries * billing * transcription * telephone and fax * miscellaneous supplies * malpractice insurance In addition, they compared the cost of telemedicine visits to traditional oncology visits, taking into consideration the same costs and found that in fiscal year 2005, teleoncology cost them $251 per visit, whereas traditional oncology vists cost $332 per visit. Their findings indicated that not only can they provide teleoncology services for cheaper than traditional visits, but that they could provide care to more individuals (can schedule more visits per day because it takes less time to do the charting, there is less travel involved, thus patient are more likely to be on time, etc.). The reduced costs of operating do not function if there is not enough of a patient base, however. Analysis found that teleoncology needed to attain, maintain, or exceed a threshold level of 200 visits per year in order to provide service at the same cost as that of a traditional clinic. It is relevant to mention that telemedicine often is slow to be adopted and this needs to be factored into a business model. Rural residents involved in this study were initially resistant/reluctant (some quite vocal and antagonistic) of telemedicine integration. However, in many of these communities there is no alternative as they cannot attract or hold many specialists. SubSpecialties Many specialties have their own telemedicine specific to their field. In order to better explain telemedicine and its applications throughout clinical medicine, unique aspects of each specialty and special considerations are explained in this section. 'Teleaudiology' Teleaudiology refers to the medical care of the hearing sensory system at a distance. Many countries and rural areas in the world simply do not have access to audiology. By making providing audiological services through telemedicine, access to these areas is improved significantly. This is especially relevant given the recent explosion of internet and cellular connectivity in relatively underdeveloped nations such as Africa and parts of Asia and India. Audiology is sometimes overlooked in rural areas where access is not easy to acquire. Newborn hearing screening programs, for example, are often not followed up on when audiologist access is limited. Given the potential for serious problems to be missed, this lack of access can result in increased medical fees for the child over the course of their life because of hearing damage that was not properly addressed Nemes, Judith. "Tele-audiology, a once-futuristic concept, is growing into a worldwide reality." Hearing Journal (2010) 63(2):19-20,22-24. Retrieved June 20th, 2012.. There is rightful concern over the technological difficulties that accompany teleaudiology. If sound is recorded or transmitted, the integrity of the sound must be preserved in order for an audiologist to make a proper diagnosis based on this information. Different recording and transmitting systems may represent the same sound in multiple ways (differences in exact volume, timbre, pitch, etc.) and can make teleaudiology a challenge. More standards need to be developed to ensure accurate sound representation. Telecardiology The remote monitoring of the heart and any clinical application thereof describes the field of cardiology. Telecardiology is one of the oldest forms of telemedicine. The earliest application was by Willem Einthoven, the inventor of the EKG, who did tests on EKG transmission over phone lines in 1906S. Serge Barold. "Willem Einthoven and the Birth of Clinical Electrocardiography a Hundred Years Ago", Cardiac Electrophysiology Review, Volume 7, Number 1 (2003), 99-104, DOI: 10.1023/A:1023667812925.. Telecardiology didn't really start to catch on until much later, with pilot programs in 1970s such as GR Medical College's implementation of wireless telecardiology. The system employed by Dr. Ajai Shanker, Dr. S. Makhija, P.K. Mantri allowed for a moving ICU van or the patients home to wirelessly send EKG information to the central station in the ICU unit at the medical college. The system also employed wired solutions (phone lines). With this system employed, pacemakers as well as EKGs could be interpreted with enough accuracy to detect arrythmias"Teletransmission of ECG Waveform: An Ingenious Low Priced Technique", Indian Heart Journal, 1982, Vol.34, No.6.. Telecardiology is employed in many ambulances today, allowing for interpretation of a 3 or 16 lead EKG prior to the admittance of a patient. Data is transmitted wirelessly using a number of different technologies - utilizing cell phone towers or 3G connectivity being quite common. 'Teledermatology' Teledermatology is a common application of telemedicine that has seen widespread adoption. This is likely due to the fact that a picture (even a low quality one) is often all that is needed to diagnose a dermatological issue as well as prescribe for it. Because video is not necessary, store and forward methods are the most commonly employed for teledermatology. Often images are sent with relevant information about the patient (pdf files are often used to send electronic health records or scanned paper health records). Dermatology, like most specialties, is often lacking in rural areas and because of the general lack of urgency with treatment may be done at a more lax schedule, unlike radiology or pathology where doctors may be posted overseas in order to provide those services overnight. As with other telemedicine specialties, telediagnosis can be a tricky topic. In most states and countries, in order for a doctor to legally have the right to diagnose, that doctor must hold a license in the same location the patient is appearing from. While this often can present issues when a diagnosis needs to be reached fairly quickly, in the case of dermatology and other specialties not as time sensitive, waiting an extra day or two for turn-around to get a doctor within the same state or country is not a big deal. An example of a teledermatology platform is MyDerm Portal. 'Teledentistry' One of the most influential programs in teledentistry was the US Army total dental access program started in 1994. Unfortunately, information was sent over telephone lines so the quality was sacrificed to stream video Chen, Jung-Wei, Hobbel, Martin H., Dunn, Kim, Johnson, Kathy A., and Zhang Jiajie. Teledentistry and its use in dental education. Journal of the American Dental Association. (2003) 134:342-346.. Growth in the education field followed soon after. Video conferencing and web based learning are currently quite common in the teledentistry field. By 2003, no insurance companies reimbursed teledentistry and its adoption has been slow. Current applications of teledentistry are rather undeveloped. This is perhaps because of the lack of useful technology. While images of a mouth, tooth, or jaw taken with a cell phone may be useful for diagnosis, surgery needs to be performed by a dentist, dental technician, or other qualified individual. These images have been deployed, however, in remote areas where dental clinics are utilized in order to serve rural and extremely isolated populations. In these cases, images may be taken with cell phone cameras in order to give the dental clinic an idea of how many tooth extractions, fillings, etc. will need to be performed on the next trip out to a particular location. <<<>>> Dental specialties such as orthodontics, periodontics, and dental imaging all lend well to teledentistry because assistants are capable of doing most of the work. Perhaps one of the biggest issues in the progression of dentistry to digital world is the lack of a standardized coding system. Health care, for example, utilized ICD-9-CM in America, and ICD-10 in Europe. Dentistry, however, has no coding system. While some terminologies support dental issues (such as SNOMED-CT and UMLS), the lack of EHRs and dental insurance companies to incorporate such technologies is slowing the progress of EHR adoption among dentists. In the future, one could envision sophisticated robotic surgery devices set up in rural areas (perhaps even shipped there and back) in order to serve the oral hygiene needs of the population. Unfortunately, it may be some time before remote surgery devices become cheap enough for dentistry to start adopting them, let alone for the price to be cheap enough for rural areas to afford implementation. Telenursing Telenursing has limited application due to the nature of nurse care. In order for many nurses to provide care for their patient, they must be around the patient. Nurses typically have less patients than doctors and a large portion of the care they provide is hands-on. However, many facilities employ large numbers of CNAs to take over a large portion of the nurses work, freeing them up to direct care in locations where doctors are less plentiful, such as in elderly care homes and psychiatric care facilities. Services which require evaluation but are simple in nature might be fulfilled through telemedicine. Examples of such services include but are not limited to: medication changes and maintenance, visual evaluation of wounds and other maladies, updating/changing problem lists, follow-up visits, etc. Some of these services might already be fulfilled via telephone communication, however, video communication could open up new possibilities in cutting costs for self-reliant patients. Another possible application is for on-call nurses to use video communication technologies to decrease costs by reducing doctor visits. Telepathology Like all other forms of telemedicine, telepathology is simply doing pathological work at a distance. This is a rapidly growing field as pathological work lends itself particularly well to telemedicine. Just like radiologists, there is often a shortage of pathologists in rural areas. By utilizing telepathology, the access to pathologists is greatly increased in many areas of the world. The term telepathology was coined by Dr. Weinstein in 1986 in an editorial where he outlined what would be necessary to create remote pathology systems Weinstein, RS, "Prospects for telepathology (Editorial)", Hum Pathol (1986)17:443-434.. In addition, Dr. Weinstein owns the first US patents for robotic telepathology systems and telepathology diagnostic networks Weinstein, Ronald S. "Telepathology diagnostic network." Patent 5,216,596. June 1, 1993.Weinstein, Ronald S. "Telepathology diagnostic network." Patent 5,297,034. March 22, 1994.. Similar to radiology, PACS (picture archiving and communication systems) are often utilized to store digital images collected. Usually these are collected from digital microscopes, however, microscopes are not always digital. They may simply be normal microscopes outfitted with a digital cameraMicroscope.com. Retrieved June 20th, 2012.. Other systems such as real-time robotic microscopy systems and virtual slide systems also exist. Real-time robotic microscopy systems consist of a digital camera and robotic systems to manipulate the positioning of the slide, level of magnification, light, and other important manipulations allowing for a pathologist to evaluate a slide much like they would in personRobotic Microscopy. UPMC Digital Pathology Imaging Group. Retrieved June 20th, 2012.. Virtual slide systems, on the other hand, create a digital image file of an entire glass slide. This file is then stored in a system (such as a PACS system) allowing one or more pathologist(s) to view and manipulate a slide digitally to extract the information that they needMolnar, B., Berczi, L., Diczhazy, C., Tagscherer, A., Varga, S. V., Szende, B., & Tulassay, Z. (2003). Digital slide and virtual microscopy based routine and telepathology evaluation of routine gastrointestinal biopsy specimens. Studies. J Clin Pathol, 56(6), 433-438.. Telepharmacy Telepharmacy is perhaps one of the oldest fields of telemedicine. However, for the purposes of this section, we will not be considering extremely simple telepharmacy technology such as the fax machine and faxed orders to encompass telepharmacy. Instead, technologies where pharmacists are remote monitoring pharmacy technicians or video conferencing patients will be considered. Telepharmacy in this case is the pharmaceutical care for locations without the physical contact of a pharmacist. This encompasses drug therapy monitoring, patient counseling, and prior/refill authorizations Angaran, DM. "Telemedicine and Telepharmacy: Current Status and Future Implications", American Journal of Health-System Pharmacy, 1999 Jul 15; Vol. 56:1405-26.. The Community Health Association of Spokane (CHAS) started a telepharmacy program in 2001 where videotelephony was employed for medication dispensing and for the counseling of patients at 6 urban and rural clinics. Remote monitoring was also employed to watch the pharmacy assistants and allowed for a reduction in pharmacist staffing while still serving the same number of peopleDennis Clifton, G.; Byer, Heather; Heaton, Kristi; Haberman, Deborah J.; and Gill, Harbir. "Provision of Pharmacy Services to Underserved Populations Via Remote Dispensing and Two-Way Videoconferencing." American Journal of Health-System Pharmacy. 2003 Dec 15; Vol. 60:2577-82. Perhaps one of the largest contributors to telepharmacy progression is the U.S. Navy. Since 2006 they have piloted a program to take telepharmacy worldwide. By the end of 2010 this consisted of over 100 navy sites covering four continents Traynor, Kate. "Navy takes Telepharmacy Worldwide", American Journal of Health-System Pharmacy. 2010 Jul 15; Vol. 67:1134-36.. Telepharmacy in the Navy consists of an audiovisual link between the pharmacy and the pharmacist. Most of the pharmacies are staffed by pharmacy technicians. Because the Navy is situated all over the world, if the usual pharmacist that serves a particular pharmacy is on vacation, sick, etc., they can simply link to a different pharmacist somewhere else Kate Traynor. Navy takes telepharmacy worldwide. Am J Health-Syst Pharm. (2010) 67:1134-1135.. When the pharmacy technician fills an order, they scan a barcode on the pill bottle, take a picture of the pills, a picture of the vial labels and send all the information to the pharmacist. The pharmacist double checks this information and can talk in real time to the pharmacy technician to clear up any issues. If counselling is needed or requested, that same audiovisual link can be used to consult in real time. The Navy's telepharmacy system utilizes a product called ScriptPro for their pharmacy needs - scriptpro includes functions such as checking the pills vs. standard reference images, verifying drug/drug interactions and drug allergies, etc. Telepsychiatry Psychiatry is well fit for telemedicine, as most psychiatric appointments involve nothing more than a doctor and a patient having a conversation. This is reflected in the fact that telepsychiatry is one of the most accepted (insurance-wise) forms of telemedicine Surface, David (January/February 2007), "Country Comfort: Mental Health Telemedicine in Rural America", Social Work 7 (1): 28–31. With the modern adoption of video chat through services such as Skype, the anxiety associated with communication over a video chat system has decreased significantly. In fact, with some children growing up without ever knowing of a time without video chat services, telepsychiatry can be almost exactly the same (or perhaps superior due to the ability to forget a camera is even in the room) as observing that same child in person. It should be noted that the first references to telepsychiatry refer to telepsychiatry as 'forensic telepsychiatry'. One such reference is made by Merideth in 1999 when the following definition is given, "the use of telecommu-nication technology to provide mental health services in a medicolegal context."Merideth P. Forensic applications of telepsychiatry. Psychiatric Annals. 1999;29(7):429–431. It should be noted that this definition does not specify the patient or patient population-subset, and is simply a term to describe telepsychiatry as a whole. Perhaps one of the greatest benefits of telepsychiatry is its ability to increase psychiatric availability to rural areas. The poor availability to mental health services in rural areas is well documented Charity G. Moore, Michael Mink, Janice C. Probst, Mark Tompkins, Andy Johnson, and Shereca Hughley. "Mental Health Risk Factors, Unmet Needs, and Provider Availability for Rural Children". Retrieved June 6th, 2012.Dianne Travers Gustafson, Kim Preston and Julia Hudson. "Mental Health: Overlooked and Disregarded in Rural America. Retrieved June 6th, 2012. Richard L. Hough, Cathleen E. Willging, Deborah Altschul, Steven Adelsheim. "Workforce Capacity for Reducing Rural Disparities in Public Mental Health Services for Adults with Severe Mental Illness". Journal of Rural Mental Health 35(2): 35-45.. The access to psychiatrists is also low in prisons John Reed, "Delivering psychiatric care to prisoners: problems and solutions." Advances in Psychiatric Treatment 2002 (8)117-125. DOI:10.1192/apt.8.2.117. Retrieved June 8th, 2012.. Similar to rural areas, telepsychiatry shows promise in increasing the availability of psychiatrists to a population subset with low access. Such a field is emerging Forensic Telepsychiatry. Telepsychiatry.slam.nhs.uk. Retrieved October 24, 2011.. It should be noted that while telepsychiatry has slowly adopted the simple name of telepsychiatry, most references to telepsychiatry involving prison inmates uses the term 'forensic telepsychiatry'. Another emerging field within telepsychiatry is for emergency management. Emergency psychiatry refers to psychiatric situations that may include attempted suicide, substance dependence, alcohol intoxication, acute depression, presence of delusions, violence, panic attacks and significant, rapid changes in behaviorDe Clercq, M.; Lamarre, S.; Vergouwen, H. (1998). Emergency Psychiatry and Mental Health Policty: An International Point of View. New York: Elsevier.. Emergency telepsychiatry currently is limited to actual telepsychiatryShore JH, Hilty DM, Yellowlees P (2007). "Emergency management guidelines for telepsychiatry". General Hospital Psychiatry 29 (3): 199–206., however, many emergency services exist for people with suicidal ideations, spousal or family abuse problems, drug abuse problems, etc. It is not hard to imagine incorporating video chat into such services to better engage the affected parties. Teleradiology Teleradiology is defined by the Merriam Webster dictionary as "radiology concerned with the transmission of digitized medical images (as X-rays, CAT scans, and sonograms) over electronic networks and with the interpretation of the transmitted images for diagnostic purposes." "Teleradiology." Merriam-Webster.com. 2012. http://www.merriam-webster.com. Retrieved 13 June 2012. Many modern teleradiology services handle, store, print, and transmit medical images using the standard known as DICOM (Digital Imaging and Communications in Medicine). The precursor to DICOM (named ACR/NEMA 300) was developed by a joint commission between the American College of Radiology (ACR) and the National Electrical Manufacturers Association (NEMA) in 1983 The DICOM Standard. http://medical.nema.org. Retrieved June 13, 2012.. In 1993 the name was changed to DICOM. The DICOM standard was developed in order to facilitate the development and implementation of picture archiving and communication systems (PACS). DICOM is generally used over other imaging formats because it contains a large amount of meta-data on images. Since the standard was developed over 30 years ago, most medical imaging technology today natively supports the DICOM standard. The following are examples of what DICOM is capable of doing involving the data and meta-data surrounding the images takenScott Foster. "Standards and Imaging." University of California, Davis. April 5th, 2012. Keynote Address.: * Confirm whether or not an image is permanently stored on a device * Can be queried by a PACS through its data or meta-data * Enables imaging equipment to obtain details of patients and scheduled examinations * Can obtain information from imaging equipment such as beginning and end time (if applicable), duration of study, dose delivered, etc. * Can send printing requests encoded for the type of printing required (x-ray film, for example) as well as ensure relative consistency between displays and printing devices by providing a calibrating service Teleradiology is particularly important when dealing with subspecialty radiologists such as MRI radiologist, neuro-radiologist pediatric radiologist, etc. Typically these radiologists only work in large metropolitan areas during daytime hours. Through the use of telemedicine they can be available 24/7 to rural areas as well. Unfortunately, mostly due to HIPAA constraints, this has yet to be adopted widely. Perhaps one of the biggest barriers to this adoption is the large EHR market with no pre-defined transmission standards. Submission through the use of standards such as HL7 (health-level 7) would allow for HIPAA compliant transmission of data, however, many commercial EHRs do not support or have limited support for HL7 and other HIE (health information exchange) standards. Teleradiology has experienced significant growth. This is mostly due to better imaging technology becoming ever more available. Many uses for xrays were replaced by CT scans, and CT scans became cheaper, driving demand up. This allowed for a large number of firms which offer teleradiology services to smaller, more rural areas where there might only be one or few radiologists. Examples of such firms include Teleradiology Solutions, Nighthawk Radiology, The Radlinx Group, and Virtual Radiologic (vRad).. Telerehabilitation Telerehabilitation is the application of telemedicine to rehabilitation endeavors. Webcams and videoconferencing technology are often employed due to the highly visual nature of many forms of rehabilitation. Because many forms of rehabilitation involve the sensory processes such as speech and language pathology, audiology, and some aspects of neuropsychology, telerehabilitation can be useful to reduce the cost of travel for both the patient and the provider. Some forms of physical therapy, occupational therapy, and neuropsychology can be overseen via telemedicine and may be useful to reduce operating costs. Utilizing telemedicine may allow for the limitation specialized care providers and an increased number of lesser trained providers such as CNAs and LVNs which will help reduce operating costs. An article in the Journal of Telemedicine and Telecare in 2006 used telerehabilitation as an integral part of a telemedicine business model to show that telemedicine can be a profitable business. This is primarily because rehabilitation services could be expanded to include more disabled people and people with chronic or acute persistant pain issues. They believe that telemedicine can greatly expand the market for rehabilitative services because most rural areas do not offer or are limited in their offering of rehabilitative services. McCue, M.J., Palsbo, S.E. (2006). Making the business case for telemedicine:an interactive spreadsheet. Telemed J E Health. 12(2): 99-106. The main limiter to the adoption of telerehabilitation is technology. Advanced technology such as telehaptics are too underdeveloped to see any true clinical applications yet. The technology necessary to assist a patient in re-learning to walk properly, for example, are simply not developed yet. For some forms of telerehabilitation, however, technology is well employed - a clinician may, for example, design a website or course which his patients can attend at home and decrease the frequency of doctor visits. 'Telesurgery' Telesurgery refers to the operation of robotic devices to perform surgery over a distance. Most modern robotic surgery devices such as the Da Vinci are technically telesurgery devices, however, the operator of the machine is usually within the same room as the patient or the immediately adjacent room. Telesurgery is still a small and growing field. Robotic surgery devices in general are currently limited by haptic technology. Haptics refers to the reproduction of the sense of touch. Within the past few years, haptics has started to find its way into robotic surgery devices. For example, researchers at Singapore's Nanyang Technological University and National University Hospital developed a gastric endoscopic device with haptic feedback in 2011. This device was used to complete several gastric tumor removal procedures in IndiaGene Ostrovsky. (2011). Flexible Robotic Endoscopy Allows for Scarless Surgeries via Mouth. Retrieved 2011-11-21.. Because the force feedback is accomplished on the proximal end (the robot's side) through the use of sophisticated sensors within the endoscopic sheath, there is no reason this information cannot be sent over any distance, opening up the possibility of robotic surgery over hundreds or thousands of miles of distanceLouis, Lawrence. (2011). The World's First Flexibile Endoscopy Robotic Surgery in the Stomach. Retrieved 2011-11-21.. Telesurgery has been performed over large distances before. The most famous example being "Operation Lindbergh" the first telesurgery performed in Strasbourg, France by a surgeon in New York City Butner, Steven E. and Ghodoussi, Moji. (2003). Transforming a Surgical Robot for Human Telesurgery. IEEE Transaction on Robotics and Automation, 19(5): 818-824. Health Information Technology Health informatics is an emerging field that deals with information technology in medicine. Telemedicine is an integral part of education and health informaticists are needed to ensure telemedicine's adoption, regulation, etc. This is because the technology for telemedicine falls under the umbrella of health information technology - computers, networks, VOIP, EHRs, etc. are necessary for telemedicine to be practiced. Popular References Popular references to telemedicine include "Web Therapy" a show starring Fiona Wallice as a teletherapist. While web therapy originally started as an online show, in 2010 Showtime announced plans to air the episodes on television. The series premiered on July 19, 2011 and ran for 10 episodes Development Update. The Futon Critic April 22, 2010. In an interview for CSDVRS, Hugh Laurie(the actor who plays Dr. Gregory House on the Fox TV drama "House."), told Sean Belanger, "Many illnesses defy diagnosis and ingenious specialists are few and far between, which is why recent technological advances in video conferencing are so exciting. Telemedicine is not just about more convenient meetings - it's about saving lives."Sean Belanger, "In need of a house call? Telemedicine is growing with advances in video conferencing. Retrieved June 10th, 2012. ---- = References =